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UNDERGROUND STORAGE TANK DISPOSITION 'TRACKING RECORD <br /> ..,....>.......>,,.w,..,u.,r,...>,....,.u.u....,.ren.>............>............. <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: THE t7' QACc <br /> FACILITY ADDRESS: /D WEST freAtir INL ez2rR,46 cZ G9 9.f3 W <br /> �j' Z <br /> TANK ID #39 - M ��- _� Tank Description: <br /> .............................................I......................... <br /> ........................t........... <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. 1,oxr o4L <br /> Address: M9 ,/ 1-IZ UjFuj 6(/i¢,/ City: j.P g Zip: `F57 � <br /> Phone #: ( 7n9 Date Tank Removed: �d/ZJ/`�3 <br /> w...,.....w..w.,......,w,ww..uu...u....,.u.,.>su <br /> ........... u...u..uu.,....,.•uu.,...... <br /> SECTION 3 -To be filled out by contractor 'decontaminating tans(': fir <br /> Tank Decontamination Contractor: LNkLG Jaz, r , 4V t�l?a i EiU/A Sr`2LlIG�S — <br /> Address: 1�1G/ `LGl E N� rA�f} City: jQ.1� <br /> Phone #: <br /> Authorized representative of contractor certifying through signature below that the tank basbeen T t'm'� in an <br /> approved manner as req iced by Cal EP <br /> Title: <br /> Signature <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: RL44n) L D� SACdA F <br /> Address: 3-5Z/S SZ City: $ACk 97MFN7Q Zip: 9 5 <br /> Phone r`: <br /> Date Tank R /U ' 2�� -� l <br /> Title: (-aidSignat . ` <br /> ` ..,...a...,...,..a,...,.u.,,.».>...>...a ..............ass......>............. <br /> ............ <br /> ............ <br /> EH 23 049 (Revised 7-10-92) page 10 <br />